Healthcare Provider Details

I. General information

NPI: 1699953687
Provider Name (Legal Business Name): FAMILY CLINIC OF WELEETKA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2008
Last Update Date: 09/28/2021
Certification Date: 09/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 W. 9TH
WELEETKA OK
74880
US

IV. Provider business mailing address

PO BOX 337
WELEETKA OK
74880-0337
US

V. Phone/Fax

Practice location:
  • Phone: 405-786-2248
  • Fax: 405-786-2006
Mailing address:
  • Phone: 405-786-2248
  • Fax: 405-786-2006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number373819
License Number StateOK

VIII. Authorized Official

Name: MS. JAN PARKER
Title or Position: MANAGER
Credential: PHYSICIAN ASSISTANT
Phone: 405-786-2248